Provider Demographics
NPI:1144764028
Name:THOMPSON, CRYSTAL DENISE (RN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DENISE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 ORIENT AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1616
Mailing Address - Country:US
Mailing Address - Phone:631-455-2654
Mailing Address - Fax:
Practice Address - Street 1:73 ORIENT AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1616
Practice Address - Country:US
Practice Address - Phone:631-455-2654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717469-1320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities